Compositions and Methods for Treatment and Prevention of Osteoarthritis

ABSTRACT

The present invention is in the fields of medicine, pharmaceuticals, neutraceuticals and rheumatology. The invention provides pharmaceutical compositions for the treatment and/or prevention of osteoarthritis in mammals, particularly humans, comprising sodium bicarbonate and calcium gluconate, and optionally comprising one or more additional components. The invention also provides methods of treating or preventing osteoarthritis by administering to a mammal, preferably via intraarticular injection, one or more compositions of the invention.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application claims the benefit of the filing date of U.S.Provisional Application No. 60/953,724, filed Aug. 3, 2007, which isincorporated herein by reference in its entirety.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention is in the fields of medicine, pharmaceuticals,neutraceuticals and rheumatology. In one aspect, the invention isrelated to the use of compositions comprising sodium bicarbonate andcalcium gluconate in methods for the treatment and/or prevention ofosteoarthritis, and to the use of such compositions in the manufactureof products for such treatment and/or prevention.

2. Related Art

Osteoarthritis

Osteoarthritis (OA) is the most common joint disease in mammals and ischaracterized by a progressive loss of articular cartilage components,mainly proteoglycans. Over time, articular cartilage in OA has beenshown to lose its mechanical resistance, elasticity and smoothness, andto be consequently worn out by the movements of the joint. This leads toreactive bone remodeling, forming osteophytes, microfractures,subchondral eburnation and pseudocysts, and the exposure of thearticular end of the bone.

Clinical manifestations of OA are joint pain, stiffness in the morningor after rest, pain at night, limited motion, joint deformity,occasionally synovitis, and variables degrees of inflammation. Jointpain in OA may originate not only from synovitis, but also fromstretching of the joint capsule or ligaments, periosteal irritation,trabecular microfractures, intraosseous hypertension or muscle spasms.

The disruption of the proteoglycans and glycosaminoglycan aggregation isaccompanied by an increase in water in the cartilaginous matrix,diminishing its rigidity. This decreased rigidity in turn increases thevulnerability of the tissue to the mechanical and chemical damage,promoting the release of Interleukin-1 (IL-1) and nitric oxide by thechondrocytes in response to the fibronectin fragments that are formed.It also increases the release of proteases with consequent collagendegradation, destabilizing the chondral matrix and further increasingwater content.

The joints that are more frequently affected by osteoarthritis are, indecreasing sequence: distal interphalangeal, first carpometacarpal,proximal interphalangeal, knees, first metatarsophalangeal, andcoxofemorals.

Osteoarthritis has high prevalence and is one of the main causes of painand incapacity in elderly people. There are no specific treatments forOA, and the treatments that are available are of high cost and are onlyfocused on controlling and diminishing the pain and inflammationassociated with OA disease (i.e., obtaining symptomatic relief) and notwith controlling, diminishing or eradicating the disease itself.

Mexican patent request number PA/A/2006/002927 entitled “Derivados deiminoácidos biciclicos como inhibidores de metaloproteinasas de lamatriz”, describes some imino acids and derivatives thereof that may beuseful in the production of pharmaceuticals for the prevention andtreatment of diseases whose evolution include an increase in matrixmetalloprotease activity, such as joint degenerative diseases,connective tissue diseases, periodontal disease, disorders of thelocomotive system, and inflammatory or carcinogenic diseases, as well asthose diseases and disorders that arise after or as a result of injuriesto the joints, meniscus, kneecaps or ligaments, disruptions in healinginjuries, bone metabolism disruptions, ulceration, stenosis,arthropathy, myalgia, anorexia or septic shock.

In Mexican patent request number PA/A/2004/000854 entitled “El uso dederivados de heparinoide para el tratamiento y diagnóstico de desordenesque se puedan tratar con heparinoides,” some heparinoid derivativecompounds useful for preventing and treating metalloproteinase-relateddiseases and disorders are disclosed.

Mexican patent request number PA/a/2003/004965 entitled “El use de laheparina de bajo peso molecular para el tratamiento de la osteoartrosis”discloses the use of heparin derivatives containing a chelating agentcovalently bound to heparinoid and a paramagnetic cation metal frommetal transition series (Sc, Ti, Cr, Mn, Fe, Co, Ni, Cu, Mo, Ru) orlanthanides. These derivatives are reported to be suitable for theproduction of drugs for certain therapeutic and diagnostic purposes, forlocalization of administered dose, and for supervision of treatmentsuccess of diseases such as osteoarthrosis and thrombosis.

U.S. Pat. Nos. 6,207,672 and 5,856,358 entitled “Cyclic and heterocyclicN-substituted α-iminohydroxamic and carboxylic acids” and “Mono- anddisulfo-substituted anthraquinones and their use for the treatment ofbone matrix disorders,” respectively, claim the use of several compoundsfor OA treatment.

Currently, however, there does not exist a specific treatment for OA;there are only certain treatment strategies that are frequently used toallow the mobility of the patient, or to control and diminish theprimary symptoms of the disease, such as pain and inflammation.

Some options employed in order to improve mobility are:

(a) Physical medicine and rehabilitation;

(b) Weight loss when the joints that support load are affected and thepatient is also overweight;

(c) Biomechanical handling such as corsets, external prosthesis, etc.

Pharmacological Treatment of Osteoarthritis Symptoms

Pharmacological treatment of the disease symptoms of OA generallyincludes a variety of approaches focused on controlling and diminishingthe pain associated with the disease. Among such approaches are thefollowing options:

(a) Administration of analgesics such as paracetamole and tramadole;

(b) Administration of non-steroidal anti-inflammatory drugs (NSAIDs),viscosupplementation, corticoids and/or narcotics;

(c) Orthopedic surgery; and

(d) Experimental treatments (e.g., transplant of cartilage andmesenquitomatoses cells, administration of cytokine inhibitors (IL-1,tumor necrosis factor a (TNF-α), etc.), administration ofmetalloprotease inhibitors, administration of nitric oxide synthetaseinhibitors, administration of growth factors and administration ofchondroprotectors).

Thus, there are many treatment modalities for OA includingnon-pharmacological (e.g., patient education, weight control, physicaland occupational therapy) and pharmacologic therapy (e.g.,intraarticular steroid injections, paracetamol, topical analgesics,nonsteroidal anti-inflammatory drugs and opioid analgesics). Thehandling of osteoarthritis is predominantly palliative, focused in themitigation of the symptoms such as pain and inflammation. Nevertheless,since existing therapeutic approaches do not attack the mechanism oforigin OA, cartilage deterioration continues despite physical and/orpharmacological attempts to treat the disease and/or its symptoms. Themost used drugs for the treatment of the osteoarthritis are the NSAIDs(Abramson S B. The role of NSAIDs in the treatment of osteoarthritis.Brandt K D, Doherty M, Lohmlander L S (Eds). Oxford University Press.2003: 251-258; Schnitzer T J. American College of Rheumatology. Updateof ACR guidelines for osteoarthritis: role of the coxibs. J Pain SymptomManage. 2002: S24-S30), which are common analgesics that reduce pain andinflammation. This type of drug includes aspirin, ibuprofen andnaproxen. They act by blocking the synthesis of prostaglandins vianon-selective inhibition of the cyclooxygenase enzyme activity (“COX”;Vane J R, Bakhle Y S, Botting R M. Cyclooxygenases 1 and 2. Annu RevPharmacol Toxicol. 1998, 38:97-120). Although the NSAIDs are the mostwidely prescribed drugs to reduce joint pain and stiffness, theinflammatory component of OA occasionally is minimal; therefore, theactual need for the anti-inflammatory effects of the NSAIDs, and thusthe benefit of administering such drugs, in OA treatment iscontroversial. Moreover, inhibition of prostaglandin biosynthesis isdirectly related to many common and occasionally severe side effectsincluding gastrointestinal bleeding, hypertension, congestive hearthfailure, hyperkalemia, renal insufficiency and platelet aggregationinhibition (Zeisel S H. Regulation of nutraceuticals. Science. 1999,285; Halsted C H. Dietary supplements and functional foods: 2 sides of acoin? Am Clin Nutr. 2003, 77:1001S-1007S; Diplock A T, Aggett P J,Ashwell M, Bornet F, Fern F B, Roberfroid M B. Scientific concepts offunctional foods in Europe; consensus document. Br J Nutr. 1999,81:S1-S27). In fact in April 2005, the U.S. Food and Drug Administration(FDA) requested to the manufacturers of NSAIDs that a warning label beincluded on NSAID products, alerting the consumer to the increased riskof cardiovascular events and intestinal bleeding that could accompanythe use of the products. These disadvantages call for an evaluation ofthe risks and benefits of such therapies for OA, in comparison with theless toxic (or at least less risky) approaches.

Another type of drugs, the Cyclo-oxygenase 2 (COX2) selectiveinhibitors, have demonstrated analgesic and anti-inflammatory efficaciesin patients with OA comparable to those of traditional NSAIDs, and animproved safety profile relative to NSAIDSs (Ramsey S D, Spencer A C,Topolski T D, Belza B, Patrick D L. Use of alternative therapies byolder adults with osteoarthritis. Arthritis Reum. 2001, 45:222-227).Nevertheless, numerous reports of heart attacks and adversecerebrovascular events have led the FDA to reevaluate the risks againstbenefits of COX-2 inhibitors. As a result of the FDA's analysis, theCOX-2 drugs rofecoxib (marketed in the US under the brand name VIOXX®)and valdecoxib (marketed in the US under the brand name EXTRA®) havebeen withdrawn from the market in the United States, after it wasreported that an increase in heart attacks was observed in patientstaking these drugs (Lane N E. Pain management in osteoarthritis: therole of COX-2 inhibitors. J rheumatol, 1997, 24:20-24). The COX-2 drugCelecoxib (marketed in the US under the brand name CELEBREX®) is stillavailable, but only with serious warning labels and recommendations ofbeing prescribed at low doses and during a limited period of time toavoid adverse effects.

In another therapeutic approach, the inflammation and moderate to severejoint pain associated with OA can be effectively relieved byintra-articular injection of corticosteroids. However, the long-termimpact and safety of such injections, especially on knee anatomicalstructure, is still unknown. Thus, while the corticosteroids are auseful form of treatment for OA, the disadvantage is that the palliatoryeffect of corticosteroid injection appears to last for only 1 to 3 weeksand that such injections could themselves also lead to long-term jointdamage. Other concerns associated with the use of corticosteroidinjection include synovitis, cutaneous atrophy (local), and steroidarthropathy.

The use of natural glucosamine and chondroitin sulfate (as foodadditives) against degeneration of articular cartilage at otherlocations has recently received much attention. Most emphasis was laidupon the reported beneficial effect of glucosamine and chondroitinsulfate on OA of the knee, and the general conclusion was that theresults were promising but the evidence insufficient to support aconclusion that such food additives were useful in the treatment orprevention of OA (Pelletier J P, Martell-Pelletier J, Raynauld, J P.Most recent developments in strategies to reduce the progression ofstructural changes in osteoarthritis: today and tomorrow. ArthritisResearch and Therapy. 2006, 8:206).

One OA treatment that has demonstrated an effectiveness of ‘70% to 90%and produces excellent results is the transplantation of culturedautologous chondrocytes. This method consists of taking chondralcellular material from the patient and seeding it in a proper culturemedium for its proliferation, and then, once enough cellular volume isachieved, implanting it in the damaged tissues to cover their defects(Vladimir B. Autologous chondrocyte transplantation. American Academy ofOrthopaedic Surgeons Annual Meeting. 2000, pp. 1-6). Despite itspromise, however, this approach to treating OA is an expensive andtime-consuming procedure.

Another OA treatment that at the present enjoys high popularity involvesthe intraarticular application of commercially available artificialsynovial fluid, such as HYALGAN® (Sanofi-Aventis US, Bridgewater, N.J.),ORTHOVISC® (DePuy Mitek, Inc, Raynham, Mass.), ARTZAL®/SUPARTZ®(Seikagaku Corpn., Tokyo, Japan) and SYNVISC® (Genzyme Corpn.,Cambridge, Mass.). This substance acts only by modifying the rheology ofthe synovial fluid, producing an almost immediate sensation of freemovement and pronounced reduction of pain in patients afflicted with OA.However, the effect of this artificial synovial fluid administration istemporary, because the material remains within the articular chamber foronly about 72 hours before it is absorbed and metabolized. In addition,the main underlying problem causing OA is not corrected by such atreatment—that is, the cartilage is not repaired from articular damage.Hence, even with such a treatment which results in temporary alleviationof OA symptoms, joint deterioration continues.

Thus, it is clear that there is a need in the art for a more specificapproach to treating and/or preventing osteoarthritis, which not onlyimproves and alleviates the symptoms associated with OA but which alsoaffects and reverses the underlying physiological causes of the disease.

BRIEF SUMMARY OF THE INVENTION

In one aspect, the present invention is related to the use of sodiumbicarbonate and calcium gluconate for the treatment and/or prevention ofosteoarthritis, as well as to pharmaceutical compositions containingsuch components and methods of manufacturing such compositions.

In one embodiment, the invention provides a pharmaceutical compositionfor the treatment of osteoarthritis in a mammal, comprising sodiumbicarbonate and calcium gluconate. In certain such embodiments, thesodium bicarbonate is present at a concentration of from about 5%-10%(w/v) (more particularly, about 6%-8% (w/v), about 6%-7% (w/v), about6.5% (w/v), or about 6.75% (w/v)), and the calcium gluconate is presentat a concentration of from about 0.5%-5% (w/v) (more particularly, about0.75%-2% (w/v), about 0.75% (w/v), about 1% (w/v), or about 1.5% (w/v)).In certain preferred embodiments, the compositions of the inventioncomprise about 6.5% (w/v) or about 6.75% (w/v) sodium bicarbonate andabout 0.75% (w/v) or about 1.5% (w/v) calcium gluconate. In one suchembodiment, the compositions comprise about 6.75% (w/v) sodiumbicarbonate and about 0.75% calcium gluconate. In another suchembodiment, the compositions comprise about 6.75% (w/v) sodiumbicarbonate and about 1.5% (w/v) calcium gluconate. The compositions ofthe invention can be in any suitable dosage form, but are preferably insolid form or aqueous solution form, and most preferably are in aqueoussolution form.

In additional embodiments, the invention provides such compositions ofthe invention which further comprise one or more additional components,particularly wherein such one or more additional components are suitablefor assisting in the treatment and/or prevention of osteoarthritis. Suchcompositions of the invention may comprise, for example, as the one ormore additional components, at least one NSAID (including but notlimited to aspirin, diclofenac, aceclofenac, ketorolac, ibuprofen,flurbiprofen, ketoprofen, and naproxen, and pharmaceutically acceptablederivatives, salts or esters thereof), at least one non-steroidalimmunophilin-dependent immunosuppressant (“NsIDI”, including but notlimited to calcineurin inhibitors such as cyclosporine, tacrolimus,ascomycin, pimecrolimus, as well as other agents (peptides, peptidefragments, chemically modified peptides, or peptide mimetics) thatinhibit the phosphatase activity of calcineurin; and rapamycin(sirolimus), fujimycin (tacrolimus) and everolimus, which bind to anFK506-binding protein, FKBP-12), at least one COX-1 inhibitor (includingbut not limited to aspirin, ibuprofen and naproxen), at least one COX-2inhibitor (including but not limited to celecoxib, rofecoxib,valdecoxib, lumiracoxib, meloxicam, tramadol, lumiracoxib, etoricoxiband nimesulide), at least one corticosterioid (including but not limitedto betamethasone, budesonide, cortisone, dexamethasone, hydrocortisone,methylprednisolone, prednisolone, prednisone and triamcinolone), atleast one glycosaminoglycan (including but not limited to glucosamine orglucosamine sulfate), at least one proteoglycan (including but notlimited to heparan sulfate proteoglycan or chondroitin sulfateproteoglycan), at least one hyaluronic acid, and synovial fluid(including but not limited to HYALGAN®, ORTHOVISC®, ARTZAL®/SUPARTZ® andSYNVISC®. Additional components suitable for inclusion in thecompositions of the present invention will be familiar to the ordinarilyskilled artisan.

In suitable embodiments, the compositions of the present invention areformulated for oral administration or parenteral administration, andpreferably for parenteral administration such as in an injectable form.In particular such embodiments, the compositions are formulated foradministration to an animal, such as a mammal, via intraarticularinjection.

In other embodiments, the invention provides methods of treating orpreventing osteoarthritis in a mammal (such as a human), comprisingadministering to said mammal an osteoarthritis-treating orosteoarthritis-preventing amount of a pharmaceutical compositioncomprising sodium bicarbonate and calcium gluconate, such as one or moreof the compositions of the invention that are described herein andabove. According to suitable such methods, the compositions areadministered to the mammal orally or parenterally, and preferablyparenterally such as via injection. In particular such methods, thecompositions are administered to the mammal via intraarticularinjection. In additional embodiments, such methods of the inventionfurther comprise administering to the mammal, preferably viaintraarticular injection, a hyperosmolar solution of sodium chloride(particularly wherein the concentration of sodium chloride in thehyperosmolar solution is about 1.77 g/mol), so as to diminish the watercontent inside the chondral matrix and restore the loss of chlorineproduced by the exchange of HCO₃ ⁺/Cl⁻.

Other preferred embodiments of the present invention will be apparent toone of ordinary skill in light of the following drawings and descriptionof the invention, and of the claims.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a flow chart which illustrates the method by whichparticipants were selected for the Kondrium™/methylprednisolone study.

FIG. 2 is a bar graph which illustrates the change in WOMAC pain indexin each treatment group evaluated after four injections. Bars withdifferent letters are significantly different (p<0.05, LSD test).

FIG. 3 is a bar graph which illustrates the change in Luquesne'sfunctional index in each treatment group evaluated after fourinjections. Bars with different letters are significantly different(p<0.05, LSD test).

DETAILED DESCRIPTION OF THE INVENTION

Unless defined otherwise, all technical and scientific terms used hereinhave the same meanings as commonly understood by one of ordinary skillin the art to which this invention belongs. Although any methods andmaterials similar or equivalent to those described herein can be used inthe practice or testing of the present invention, the preferred methodsand materials are described hereinafter.

Definitions

About: As used herein when referring to any numerical value, the term“about” means a value of ±10% of the stated value (e.g., “about 50° C.”encompasses a range of temperatures from 45° C. to 55° C., inclusive;similarly, “about 100 mM” encompasses a range of concentrations from 90mM to 110 mM, inclusive).

Bound: As used herein, the term “bound” refers to binding or attachmentthat may be covalent, e.g., by chemically coupling, or non-covalent,e.g., ionic interactions, hydrophobic interactions, hydrogen bonds, etc.Covalent bonds can be, for example, ester, ether, phosphoester,thioester, thioether, urethane, amide, amine, peptide, imide, hydrazone,hydrazide, carbon-sulfur bonds, carbon-phosphorus bonds, and the like.The term “bound” is broader than and includes terms such as “coupled,”“conjugated” and “attached.”

Disease, disorder, condition: As used herein, the terms “disease” or“disorder” refer to any adverse condition of a human or animal includingtumors, cancer, allergies, addiction, autoimmunity, infection, poisoningor impairment of optimal mental or bodily function. “Conditions” as usedherein includes diseases and disorders but also refers to physiologicstates. For example, fertility is a physiologic state but not a diseaseor disorder; hence, compositions suitable for preventing pregnancy bydecreasing fertility would therefore be described herein as a treatmentof a condition (fertility), but not a treatment of a disorder ordisease. Other conditions encompassed by the use of that term hereinwill be understood by those of ordinary skill in the art.

Effective Amount: As used herein, the term “effective amount” refers toan amount of a given compound, conjugate or composition that isnecessary or sufficient to realize a desired biologic effect. Aneffective amount of a given compound, conjugate or composition inaccordance with the methods of the present invention would be the amountthat achieves this selected result, and such an amount can be determinedas a matter of routine by a person skilled in the art, using assays thatare known in the art and/or that are described herein, without the needfor undue experimentation. For example, an effective amount for treatingor preventing osteoarthritis could be that amount necessary to preventthe development and/or progression of the symptoms and/or underlyingphysiological causes of osteoarthritis, such as preventing or reducingan increase in water in the cartilaginous matrix which diminishing therigidity of the matrix, reducing or preventing joint pain or stiffness,reducing or preventing disruption of the proteoglycans and/orglycosaminoglycans in one or more joints, etc. The term is alsosynonymous with “sufficient amount.” The effective amount for anyparticular application can vary depending on such factors as thedisease, disorder or condition being treated, the particular compositionbeing administered, the route of administration, the size of thesubject, and/or the severity of the disease or condition. One ofordinary skill in the art can determine empirically the effective amountof a particular compound, conjugate or composition of the presentinvention, in accordance with the guidance provided herein, withoutnecessitating undue experimentation.

One, a, or an: When the terms “one,” “a,” or “an” are used in thisdisclosure, they mean “at least one” or “one or more,” unless otherwiseindicated. As such, the terms “a” (or “an”), “one or more,” and “atleast one” can be used interchangeably herein.

Peptide, polypeptide, protein: As used herein, the term “polypeptide” isintended to encompass a singular “polypeptide” as well as plural“polypeptides,” and refers to a molecule composed of monomers (aminoacids) linearly linked by amide bonds (also known as peptide bonds). Theterm “polypeptide” refers to any chain or chains of two or more aminoacids, and does not refer to a specific length of the product. Thus,peptides, dipeptides, tripeptides, oligopeptides, “protein,” “amino acidchain,” or any other term used to refer to a chain or chains of two ormore amino acids, are included within the definition of “polypeptide,”and the term “polypeptide” may be used instead of, or interchangeablywith any of these terms. The term “polypeptide” is also intended torefer to the products of post-expression modifications of thepolypeptide, including without limitation glycosylation, acetylation,phosphorylation, amidation, derivatization by known protecting/blockinggroups, proteolytic cleavage, or modification by non-naturally occurringamino acids. A polypeptide may be derived from a natural biologicalsource or produced by recombinant technology, but is not necessarilytranslated from a designated nucleic acid sequence. It may be generatedin any manner, including by chemical synthesis. In accordance with thisdefinition, polypeptides used in the present invention may be of a sizeof about 3 or more, 5 or more, 10 or more, 20 or more, 25 or more, 50 ormore, 75 or more, 100 or more, 200 or more, 500 or more, 1,000 or more,or 2,000 or more amino acids. Polypeptides may have a definedthree-dimensional structure, although they do not necessarily have suchstructure. Polypeptides with a defined three-dimensional structure arereferred to as folded, and polypeptides which do not possess a definedthree-dimensional structure, but rather can adopt a large number ofdifferent conformations, and are referred to as unfolded. As usedherein, the term glycoprotein refers to a protein coupled to at leastone carbohydrate moiety that is attached to the protein via anoxygen-containing or a nitrogen-containing side chain of an amino acidresidue, e.g., a serine residue or an asparagine residue.

By an “isolated” polypeptide or a fragment, variant, or derivativethereof is intended a polypeptide that is not in its natural milieu. Noparticular level of purification is required. For example, an isolatedpolypeptide can be removed from its native or natural environment.Recombinantly produced polypeptides and proteins expressed in host cellsare considered isolated for purposed of the invention, as are native orrecombinant polypeptides which have been separated, fractionated, orpartially or substantially purified by any suitable technique.

Also included as “polypeptides” as used herein are fragments,derivatives, analogs, or variants of the foregoing polypeptides, and anycombination thereof. Fragments of polypeptides, as that term or phraseis used herein, include proteolytic fragments, as well as deletionfragments, in addition to specific fragments discussed elsewhere herein.Variants of polypeptides useful in accordance with the present inventioninclude fragments as described above, and also polypeptides with alteredamino acid sequences due to amino acid substitutions, deletions, orinsertions. Variants may occur naturally or be non-naturally occurringNon-naturally occurring variants may be produced using art-knownmutagenesis techniques. Variant polypeptides may comprise conservativeor non-conservative amino acid substitutions, deletions or additions.Variant polypeptides may also be referred to herein as “polypeptideanalogs.” Derivatives of polypeptides useful in accordance with thepresent invention are polypeptides which have been altered so as toexhibit additional features not found on the native polypeptide.Examples include fusion proteins, polypeptides having one or moreresidues chemically derivatized by reaction of a functional side group,and peptides that contain one or more naturally occurring amino acidderivatives of the twenty standard amino acids (for example,4-hydroxyproline may be substituted for proline; 5-hydroxylysine may besubstituted for lysine; 3-methylhistidine may be substituted forhistidine; homoserine may be substituted for serine; ornithine may besubstituted for lysine; etc.).

Treatment: As used herein, the terms “treatment,” “treat,” “treated” or“treating” refer to prophylaxis and/or therapy, particularly wherein theobject is to prevent or slow down (lessen) an undesired physiologicalchange or disorder, such as the development and/or progression ofosteoarthritis. Beneficial or desired clinical results include, but arenot limited to, alleviation of symptoms, diminishment of the extent ofdisease, stabilized (i.e., not worsening) state of disease, delay orslowing of disease progression, amelioration or palliation of thedisease state, and remission (whether partial or total), whetherdetectable or undetectable. “Treatment” can also mean prolongingsurvival and/or increased quality of life as compared to expectedsurvival and/or quality of life if not receiving treatment. Those inneed of treatment include those already with the condition or disorder(e.g., osteoarthritis) as well as those prone to have the condition ordisorder or those in which the condition or disorder is to be prevented.By “subject” or “individual” or “animal” or “patient” or “mammal,” ismeant any subject, particularly a mammalian subject, for whom diagnosis,prognosis, or therapy is desired. Mammalian subjects include humans andother primates, domestic animals, farm animals, and zoo, sports, or petanimals such as dogs, cats, guinea pigs, rabbits, rats, mice, horses,donkeys, mules, burros, cattle, cows, and the like.

Overview

The present invention is related to the use of sodium bicarbonate andcalcium gluconate for the treatment and/or prevention of joint diseasessuch as osteoarthritis, as well as to pharmaceutical compositionscontaining such components and methods of manufacturing suchcompositions. In additional embodiments, the invention provides methodsof use of such compositions in the manufacture of products for treatmentand/or prevention of joint diseases such as osteoarthritis. According tocertain such embodiments, the present invention provides for a carefullyplanned combination for the treatment of osteoarthritis, for example byadministration of a solution that activates the buffer capacity ofproteins that forms the cartilage (e.g., a solution of sodiumbicarbonate) which promotes the organification of ionized calcium,together with a solution that allows the linkage between chondrals andbone proteins (e.g., a solution of calcium gluconate). In otherembodiments, the compositions provided by the present invention mayfurther comprise one or more additional components or compounds that areuseful in treating or preventing joint diseases such as OA, and/or thesymptoms associated with such joint diseases; such embodiments are alsodescribed in further detail hereinbelow.

The compositions and methods provided by the present invention not onlyalleviate and/or remedy the symptoms of joint diseases such as OA (e.g.,joint pain and inflammation), but also attacks the different factorsthat gives rise to joint diseases such as OA and thereby alleviates,treats and/or eradicates the underlying physiological causes of thesymptoms and disease state itself. The simple and low cost compositionsand methods useful for treating and/or preventing joint diseases such asOA, provided by the present invention, were developed based on therestoration of the articular surface of the synovial joints aftercartilage loss or degeneration. As described hereinbelow, certain suchembodiments of the invention involve administration, such as viaintraarticular injection, of a solution comprising sodium bicarbonateand calcium gluconate, particularly aqueous compositions wherein thesodium bicarbonate concentration ranges from 0.1% (w/v) to 99.9% (w/v)(particularly about 6.5% (w/v) or about 6.75% (w/v)), and the calciumgluconate concentration ranges from 0.1% (w/v) to 99.9% (w/v)(particularly about 0.75% (w/v) to about 1.5% (w/v)). In certain suchembodiments, the sodium bicarbonate is present at a concentration offrom about 5%-10% (w/v) (more particularly, about 6%-8% (w/v), about6%-7% (w/v), about 6.5% (w/v), or about 6.75% (w/v)), and the calciumgluconate is present at a concentration of from about 0.5%-5% (w/v)(more particularly, about 0.75%-2% (w/v), about 0.75% (w/v), about 1%(w/v), or about 1.5% (w/v)). In certain preferred embodiments, thecompositions of the invention comprise about 6.5% (w/v) or about 6.75%(w/v) sodium bicarbonate and about 0.75% (w/v) or about 1.5% (w/v)calcium gluconate. In one such embodiment, the compositions compriseabout 6.75% (w/v) sodium bicarbonate and about 0.75% calcium gluconate.In another such embodiment, the compositions comprise about 6.75% (w/v)sodium bicarbonate and about 1.5% (w/v) calcium gluconate.

While not wishing to be bound to any particular theory, it is believedthat one of the components of the compositions of the present invention,sodium bicarbonate, works in the present compositions and methods byactivating the buffer capacity of certain proteins in the joint, therebyallowing the linkage of ionized calcium (calcium organification) to thechondral and bony proteins in the joint, which in turn strengthens thejoint and bone matrix. In this way, it is believed that sodiumbicarbonate stimulates the buffer capacity of chondral and bone proteinsin order to produce the organification of ionized calcium of thoseproteins.

Similarly, while not wishing to be bound to any particular theory, it isbelieved that another of the components of the compositions of thepresent invention, calcium gluconate, works in the present compositionsand methods to promote the linkage between chondral proteins in thejoint, thereby forming a coverage over the subchondral bone which limitsthe further disruption of proteins within the joint and surrounding bonematrix. In this way, it is believed that calcium gluconate promotes thelinkage between chondral and bony proteins, which thereby favors theformation of an interface covering the subchondral bone, limiting thedisruption of proteins and increasing the structural rigidity of thebony and cartilaginous matrix.

Using the compositions and methods of the present invention as describedherein, joint pain associated with joint diseases such as OA isdiminished and the articular mobility is improved. The wateraccumulation inside the matrix and the hypochloremia in theextracellular liquid as a result of bicarbonate administration can alsobe regulated by the administration of a hyperosmolar solution of sodiumchloride (preferably at a concentration of about 1.7 g/mol to about 2.0g/mol, more preferably at a concentration of about 1.75 g/mol to about1.85 g/mol, and still more preferably at a concentration of about 1.77g/mol).

The compositions and methods provided by the present invention can beused not only for the treatment and/or prevention of OA, but also forthe treatment and/or prevention of any other inflammatory disease thatproduces joint damage. Additionally, the use of the compositions andmethods of the present invention is not restricted to human beings; theycan be also used in any mammal, alone or in combination with any othermedicine or pharmaceutically active compound designed for the treatmentof joint disease symptoms, or any other substance that is capable ofintraarticular administration. Such uses and additional compositions arealso described in detail hereinbelow.

Compositions

Thus in one embodiment, the invention provides a pharmaceuticalcomposition for the treatment of joint diseases, including but notlimited to osteoarthritis, in a mammal. Exemplary pharmaceuticalcompositions according to this aspect of the invention comprise sodiumbicarbonate and calcium gluconate. In certain such embodiments, thesodium bicarbonate is present at a concentration of from about 0.1% toabout 99.9% (w/v); suitably from about 1% to about 50% (w/v) or about2.5% to about 25% (w/v); more suitably about 5% to about 10% (w/v); andstill more suitably about 6% to about 8% (w/v), about 6% to about 7%(w/v), about 6.75% (w/v), or about 6.5% (w/v)). Similarly, in certainsuch embodiments, the calcium gluconate is present at a concentration offrom about 0.1% to about 99.9% (w/v), suitably from about 0.25% to about50% (w/v), about 0.5% to about 25% (w/v), about 0.5% to about 10% (w/v)or about 0.5% to about 5% (w/v); more suitably, from about 0.75% toabout 2% (w/v); still more suitably about 0.75% (w/v) to about 1.5%(w/v); and still more suitably about 0.75% (w/v), about 1% (w/v), orabout 1.5% (w/v)). In particularly preferred embodiments, thecompositions of the invention comprise about 6.75% (w/v) sodiumbicarbonate and about 0.75% (w/v) calcium gluconate. In anotherparticularly preferred embodiment, the compounds of the presentinvention comprise about 6.75% (w/v) sodium bicarbonate and about 1.5%(w/v) calcium gluconate.

In additional embodiments, the compositions of the invention can furthercomprise one or more additional components, particularly wherein suchone or more additional components are suitable for assisting in thetreatment and/or prevention of osteoarthritis. Such compositions of theinvention may comprise, for example, as the one or more additionalcomponents, at least one NSAID (including but not limited to aspirin,ibuprofen, aceclofenac, diclofenac, naproxen, etodolac, flurbiprofen,fenoprofen, ketoprofen, suprofen, fenbufen, fluprofen, tolmetin sodium,oxaprozin, zomepirac, sulindac, indomethacin, piroxicam, mefenamic acid,nabumetone, meclofenamate sodium, diflunisal, flufenisal, piroxicam,ketorolac, sudoxicam and isoxicam, and pharmaceutically acceptablederivatives, salts or esters thereof).

In additional embodiments, the compositions of the invention may furthercomprise at least one non-steroidal immunophilin-dependentimmunosuppressant. By a “non-steroidal immunophilin-dependentimmuno-suppressant” or “NsIDI” is meant any non-steroidal agent thatdecreases proinflammatory cytokine production or secretion, binds animmunophilin, or causes a down regulation of the proinflammatoryreaction. NsIDIs suitable for inclusion in the present compositionsinclude, but are not limited to, calcineurin inhibitors, such ascyclosporine, tacrolimus, ascomycin, pimecrolimus, as well as otheragents (peptides, peptide fragments, chemically modified peptides, orpeptide mimetics) that inhibit the phosphatase activity of calcineurin.NsIDIs also include rapamycin (sirolimus) and everolimus, which bind toan FK506-binding protein, FKBP-12, and block antigen-inducedproliferation of white blood cells and cytokine secretion).

In additional embodiments, the compositions of the invention may furthercomprise at least one COX-1 inhibitor (including but not limited toaspirin, ibuprofen and naproxen).

In additional embodiments, the compositions of the invention may furthercomprise at least one COX-2 inhibitor (including but not limited tocelecoxib, rofecoxib, valdecoxib, lumiracoxib, meloxicam, tramadol,lumiracoxib, etoricoxib and nimesulide, and the like).

In additional embodiments, the compositions of the invention may furthercomprise at least one corticosterioid (including but not limited tobetamethasone, budesonide, cortisone, dexamethasone, hydrocortisone,methylprednisolone, prednisolone, prednisone and triamcinolone).

In additional embodiments, the compositions of the invention may furthercomprise at least one glycosaminoglycan (including but not limited toglucosamine or glucosamine sulfate).

In additional embodiments, the compositions of the invention may furthercomprise at least one proteoglycan (including but not limited to heparansulfate proteoglycan or chondroitin sulfate proteoglycan).

In additional embodiments, the compositions of the invention may furthercomprise at least one hyaluronic acid.

In additional embodiments, the compositions of the invention may furthercomprise synovial fluid, such as artificial synovial fluid. Synovialfluids suitable for use in accordance with the present invention areavailable commercially, including but not limited to HYALGAN®(Sanofi-Aventis US, Bridgewater, N.J.), ORTHOVISC® (DePuy Mitek, Inc,Raynham, Mass.), ARTZAL®/SUPARTZ® (Seikagaku Corpn., Tokyo, Japan) andSYNVISC® (Genzyme Corpn., Cambridge, Mass.).

In other embodiments, the compositions of the invention further comprisecombinations of two or more of the additional components describedabove. Further additional components suitable for inclusion in thecompositions of the present invention will be familiar to the ordinarilyskilled artisan.

The concentrations, absolute amounts and relative amounts (i.e.,relative to the concentration or absolute amounts of sodium bicarbonateand calcium gluconate) of the additional one or more compounds or agentsthat are optionally included in the compositions of the invention willbe familiar to one of ordinary skill in the art. For example, theadditional compounds or agents (e.g., one or more corticosteroids, oneor more NSAIDs, one or more NsIDIs, one or more COX-1 or -2 inhibitors,etc.), can be present in any amount, for example about 0.01% to about99% (e.g., about 0.01%, about 0.1%, about 1%, about 10%, about 20%,about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, orabout 90%), on a weight/volume (w/v) or weight/weight (w/w) basis,relative to the concentration or absolute amounts of sodium bicarbonateand calcium gluconate that are present in the compositions.

The compositions of the invention can be in any suitable dosage form,but are preferably in solid form or aqueous solution form, and mostpreferably are in aqueous solution form such as in a buffered saltsolution comprising one or more physiologically acceptable salts,buffers and/or carriers, such as a sufficient amount of apharmaceutically acceptable buffer to maintain the pH of the compositionwithin a range of from about 4.5 to about 7.4, a sufficient amount of anisotonicity agent to yield an osmolality of about 220 mosmol/kg to about350 msomol/kg and QS water. The compositions of the present inventionthat are provided in solution form may optionally be preserved,aseptically manufactured and/or sterilized, for example, by filtrationthrough a bacterial-retaining filter. While preservatives are useful inlimiting concerns related to chemical degradation or bacterial growth inthe liquid formulations of the present invention, the presence of thesepreservatives can themselves cause stinging, inflammation or irritation.Therefore, in order to reduce the possibility of such adverse events, inone embodiment, the liquid dosage forms disclosed herein can be preparedfree, or substantially free, of preservatives. As used herein the phrase“free, or substantially free, of preservatives” means that the liquidformulations contain less than about 0.0001% (weight/volume) of apreservative, more suitably less than about 0.00001% (weight/volume) ofa preservative, and most suitably, no preservative.

The formulations to be used for in vivo administration must be sterile.This is readily accomplished by filtration through sterile filtrationmembranes. Use of such membrane filters can eliminate the need forpreservatives in the various liquid formulations of the presentinvention. However, certain liquid compositions of the invention mayfurther comprise one or more preservatives and/or one or morestabilizers. Preservatives that are suitable for use in the compositionsof the invention include, but are not limited to, edetic acid and theiralkali salts such as disodium EDTA (also referred to as “disodiumedetate” or “the disodium salt of edetic acid”) and calcium EDTA (alsoreferred to as “calcium edetate”), benzyl alcohol, methylparaben,propylparaben, butylparaben, chlorobutanol, phenylethyl alcohol,benzalkonium chloride, thimerosal, propylene glycol, sorbic acid, and‘benzoic acid derivatives. The preservatives should be used at aconcentration of from about 0.001% to about 0.5% (w/v) in the finalcomposition. The combination of benzalkonium chloride, used at aconcentration of from about 0.001% to about 0.5% or preferably fromabout 0.005% to about 0.1% (w/v), and edetic acid (as a disodium salt),used at a concentration of from about 0.005% to about 0.1% (w/v), arethe preferred preservative/stabilizer combination used in thecompositions of the present invention.

In other embodiments, preservative-free liquid formulations andcompositions of the present invention can also be provided in singleunit-dose containers. Such containers are acceptable to deliver thetherapeutic dose of the compositions of the invention, particularlytopically, orally, transdermally or via injection. In certain suchembodiments of the invention, the compositions can be effectivelycontained in a package comprising a container with a volume capacity ofabout 1 mL to about 10 mL. In other such embodiments of the invention,particularly those in which the compositions of the invention areprovided in a dosage form suitable for parenteral administration, e.g.,via intraarticular injection, the compositions can be effectivelycontained in a package comprising a syringe containing one or more ofthe compositions of the invention, particularly wherein the syringecontaining the composition is itself contained within sterile packaging;in such embodiments, the sterile packaging is opened, and thecomposition of the invention is delivered to the affected joint of thepatient, e.g., via intraarticular injection, and the syringe andpackaging are then discarded. This use of single unit-dose containerseliminates the concern of contamination for the user (or other outsidesources), as once the unit-dose container is opened and a single dose ofthe present formulations or compositions is delivered, the container isdiscarded.

The compositions of the present invention can be administered to apatient via any suitable mode of administration, including orally,buccally, topically, transdermally, sublingually, parenterally or thelike. In certain embodiments, the compositions are administered directlyto the joint in which osteoarthritis or another joint disease ordisorder has manifested itself. Such administration can be accomplishedvia topical or transdermal administration using approaches andmechanisms described elsewhere herein and others that will be familiarto the ordinarily skilled artisan. Such direct administration to thejoint can also be accomplished via direct intraarticular injection ofone or more compositions of the invention into the afflicted joint orthe surrounding articular space. Methods of intraarticular injection ofpharmaceutical compositions are well within the level of skill of theordinarily skilled artisan, and are also described hereinbelow.

Thus, in certain embodiments, the compositions of the invention may beformulated into forms for oral administration, including solid dosageforms or liquid dosage forms. In alternative embodiments, thecompositions of the invention may be formulated into forms for directadministration to the mucosa, including the buccal mucosa (i.e., buccaladministration) or oral mucosa under the tongue (i.e., sublingualadministration). Solid dosage forms for oral administration includecapsules, tablets, pills, powders, particles and granules. In such soliddosage forms, the compositions of the invention are mixed with at leastone pharmaceutically acceptable excipient or carrier such as (a) fillersor extenders such as starches, lactose, sucrose, glucose, mannitol,dicalcium phosphate and microcrystalline cellulose; (b) binders such assodium carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidone,and acacia; (c) disintegrating agents such as agar-agar, calciumcarbonate, potato or tapioca starch, alginic acid, certain silicates,sodium carboxymethyl cellulose, pregelatinized starch and sodium starchglycolate; (d) lubricants such as calcium stearate, magnesium stearate,stearic acid, solid polyethylene glycols, sodium lauryl sulfate, andmixtures thereof; and/or (e) glidants such as talc, silicon dioxide andstarch. In the case of capsules, tablets and pills, the dosage form mayalso comprise buffering agents. Solid compositions of a similar type mayalso be employed as fillers in soft and hard filled gelatin capsulesusing such excipients as lactose or milk sugar as well as high molecularweight polyethylene glycols, oils and the like. The solid dosage formsof tablets, dragees, capsules, pills, and granules can be prepared withcoatings or shells such as enteric coatings and other coatings that arewell known in the pharmaceutical formulating art. The solid dosage formsalso may optionally contain opacifying, coloring and/or flavoringagents, and can also be formulated such that they release the activeingredient(s) only, or preferentially, in a certain part of theintestinal tract, optionally in a delayed manner (see U.S. Pat. No.5,271,946, the disclosure of which is incorporated herein by referencein its entirety). Examples of embedding compositions which can be usedinclude polymeric substances and waxes. The active compounds can also bein micro-encapsulated form, if appropriate, with one or more of theabove-mentioned excipients.

In other embodiments, the compositions of the invention are formulatedinto dosage forms suitable for parenteral administration. For example,liquid dosage forms of the compositions of the present invention thatare suitable for parenteral (including via injection) or oraladministration include pharmaceutically acceptable emulsions, solutions,suspensions, syrups and elixirs. In addition to the active compound(s),the liquid dosage forms may contain inert diluents and/or solventscommonly used in the art. Water is the solvent of choice for theformulations of the invention; however, combinations of water with otherphysiologically acceptable solvents as required are also satisfactoryfor use. Other solvents, solubilizing agents and emulsifiers suitablefor use in place of, or in addition to, water include but are notlimited to saturated aliphatic mono- and polyvalent alcohols whichcontain 2-6 carbon atoms (including, but not limited to, ethanol,1,2-propylene glycol, sorbitol, and glycerine), polyglycols such aspolyethylene glycols, and surfactants/emulsifiers like the fatty acidesters of sorbitan, and mixtures thereof. Oils, in particular,cottonseed, peanut, or corn oils, may also be added to the compositions.The combination of the additional solvents in the aqueous solutionshould preferably not exceed about 15% (w/v) of the total composition.Besides inert diluents, the oral compositions can also include adjuvantssuch as wetting agents, emulsifying and suspending agents (e.g.,microcrystalline cellulose, sodium carboxymethyl cellulose,hypromellose, carbopol and the like), surfactants, sweetening,flavoring, and perfuming agents, including those described in furtherdetail herein below. Liquid dosage forms that provide the activeingredient(s) in suspension may comprise, in addition to the activecompound(s), one or more suspending agents such as microcrystallinecellulose, magnesium aluminum silicate, bentonite, agar-agar,hypromellose, sodium carboxymethyl cellulose, carbopol/carbomer, pectin,acacia, tragacanth or their mixtures.

Suitable formulations for parenteral administration (e.g., viainjection, particularly intraarticular injection) include aqueoussolutions of the active compounds in water-soluble form, for examplewater-soluble salts and alkaline solutions. Alkaline salts can includeammonium salts prepared, for example, with Tris, choline hydroxide,bis-Tris propane, N-methylglucamine, or arginine. In addition,suspensions of the active compounds as appropriate oily injectionsuspensions can be administered. Suitable lipophilic solvents orvehicles include fatty oils, for example, sesame oil, or synthetic fattyacid esters, for example, ethyl oleate or triglycerides or polyethyleneglycol-400 (the compounds are soluble in PEG-400). Aqueous injectionsuspensions can contain substances that increase the viscosity of thesuspension, for example sodium carboxymethyl cellulose, sorbitol, and/ordextran. Optionally, the suspension may also contain stabilizers.

Certain compositions of the invention may further comprise one or moresolubility-enhancing agents that are used to improve the solubility ofthe compound(s) used as active ingredients in the compositions of theinvention. Solubility-enhancing agents that are suitable for use in thecompositions of the invention include, but are not limited to,polyvinylpyrrolidone (preferably grades 25, 30, 60, or 90), poloxamer,polysorbate 80, sorbitan monooleate 80, and polyethylene glycols(molecular weights of 200 to 600).

Certain compositions of the invention may further comprise one or moreagents that are used to render the composition isotonic, particularly inthose compositions in which water is used as a solvent. Such agents areparticularly useful in compositions formulated for parenteraladministration, particularly via intraarticular injection, since theyadjust the osmotic pressure of the formulations to the same osmoticpressure as the injection site. Agents that are suitable for such a usein the compositions of the invention include, but are not limited to,sodium chloride, sorbitol, propylene glycol, dextrose, sucrose, andglycerine, and other isotonicity agents that are known in the art (see,e.g., Reich et al., “Chapter 18: Tonicity, Osmoticity, Osmolality andOsmolarity,” in: Remington: The Science and Practice of Pharmacy, 20thEdition, Lippincott Williams and Wilkins, Philadelphia, Pa. (2000)).

It is desirable that the compositions of the present invention that areto be administered in liquid form (including orally, topically orparenterally applied formulations) have a pH of about 4.5 to about 7.8,and preferably have a pH of about 5.5 to about 7.4, for physiologicalreasons. Accordingly, in additional embodiments, the compositions of theinvention may further comprise one or more buffering agents orcombinations thereof, that are used to adjust and/or maintain thecompositions into the desired pH range. Adjustment of pH or bufferingagents that are suitable for use in the compositions of the inventioninclude, but are not limited to, citric acid, sodium citrate, sodiumphosphate (dibasic, heptahydrate form), and boric acid or equivalentconventional buffers, or combinations thereof. The appropriate amountsof buffers and buffering agents, or combinations thereof, that are to beused in the compositions of the invention are readily determined bythose of ordinary skill without undue experimentation, particularly inview of the guidance contained herein and in standard formularies suchas the United States Pharmacopoeia, Remington: The Science and Practiceof Pharmacy, and the like, the disclosures of which are incorporatedherein by reference in their entireties.

Methods of Use

In additional embodiments of the invention, the compositions of thepresent invention can be used therapeutically in regimens for treatingmammals afflicted with certain diseases, particularly with certain jointdisorders such as osteoarthritis and other such disorders describedelsewhere herein and that will be familiar to the ordinarily skilledartisan. Thus, in additional embodiments, the invention provides methodsof treating or preventing a joint disease or disorder such asosteoarthritis in a mammal (such as a human), comprising toadministering to said mammal an osteoarthritis-treating orosteoarthritis-preventing amount of a composition comprising sodiumbicarbonate and calcium gluconate, and optionally further comprising oneor more additional components useful in treating or preventing a jointdisease and/or the symptoms associated therewith. In relatedembodiments, the invention provides methods of reducing or preventingthe progression of a joint inflammation or injury to a more advanceddegenerative joint disease, such as OA, in a patient, comprisingadministering to the patient a therapeutically effective amount of oneor more of the compositions of the present invention. Compositionssuitable for accomplishing such methods of the invention include thecompositions of the invention that are described herein.

According to certain such methods of the invention, one or morecompositions of the present invention are administered to a patient,such as a patient suffering from or predisposed to osteoarthritis or asimilar joint disease, via any suitable mode of administration,including orally, buccally, topically, transdermally, sublingually,parenterally or the like. In certain embodiments, the compositions areadministered directly to the joint in which osteoarthritis or anotherjoint disease or disorder has manifested itself. Such administration canbe accomplished via topical or transdermal administration usingapproaches and mechanisms described elsewhere herein and others thatwill be familiar to the ordinarily skilled artisan. According to othersuitable such methods, the compositions are administered to the mammalorally or parenterally, and preferably parenterally such as viainjection.

In particular such methods, the compositions are administered to themammal via intraarticular injection into the afflicted joint or thesurrounding articular space. Methods of intraarticular injection ofpharmaceutical compositions are well within the level of skill of theordinarily skilled artisan, and are also described hereinbelow.

Suitable dosages (e.g., amounts, volumes, etc.) of the compositions ofthe invention will be apparent from the Examples below. In certainembodiments, a per injection volume of between about 2 mL to about 10 mL(suitably about 2 mL, about 2.5 mL, about 3 mL, about 3.5 mL, about 4mL, about 4.5 mL, about 5 mL, about 5.5 mL, about 6 mL, about 6.5 mL,about 7 mL, about 7.5 mL, about 8 mL, about 8.5 mL, about 9 mL, about9.5 mL or about 10 mL) of one or more of the compositions of the presentinvention is introduced into the mammal. Other suitable dosages will bereadily apparent to those of ordinary skill based on the disclosureherein and knowledge that is readily available to the ordinarily skilledartisan.

In additional embodiments, such methods of the invention furthercomprise administering to the mammal, preferably via intraarticularinjection, a hyperosmolar solution of sodium chloride, preferablywherein the solution is prepared according to the methods describedabove for preparation of the compositions of the invention. Thus, inconjunction with administration of one or more of the compositions ofthe invention to the patient, the patient is also administered ahyperosmolar solution of sodium chloride at the same site as theadministration of the one or more compositions of the invention. By “inconjunction with administration of one or more compositions of theinvention” is meant that the hyperosmolar sodium chloride composition isadministered contemporaneously with (i.e., just prior to, at the sametime as, or just after) the administration to the patient of one or morecompositions of the invention, or some time later such as at the end ofa multi-month regimen of administration of the compositions of theinvention, to the patient. In suitable such embodiments, theconcentration of sodium chloride in the hyperosmolar solution is about1.7 g/mol to about 2 g/mol, more suitably about 1.7 g/mol to about 2.0g/mol or about 1.75 g/mol to about 1.85 g/mol, and still more suitablyabout 1.77g/mol. Suitably, a per injection volume of between about 2 mLto about 10 mL (suitably about 2 mL, about 2.5 mL, about 3 mL, about 3.5mL, about 4 mL, about 4.5 mL, about 5 mL, about 5.5 mL, about 6 mL,about 6.5 mL, about 7 mL, about 7.5 mL, about 8 mL, about 8.5 mL, about9 mL, about 9.5 mL or about 10 mL) of the hyperosmolar sodium chloridesolution is introduced into the mammal. While not wishing to be bound toany particular theory, it is thought that the administration of ahyperosmolar solution of sodium chloride acts to diminish the watercontent inside the chondral matrix, thereby reversing the loss ofchlorine produced by the exchange of HCO₃ ⁺/Cl⁻.

According to the methods of the invention, the compositions of theinvention (and optionally the hyperosmolar solution of sodium chloride)can be administered to the patient according to a wide variety of dosingschedules. For example, the compositions can be administered once dailyfor a predetermined amount of time (e.g., four to eight weeks, or more),or according to a weekly schedule (e.g., one day per week, two days perweek, three days per week, four days per week, five days per week, sixdays per week or seven days per week) for a predetermined amount of time(e.g., four to eight weeks, or more). A specific example of a “onceweekly” dosing schedule is administration of the compositions of theinvention on days 1, 8, 15 and 22 of the treatment period. Inalternative embodiments the compositions of the invention may beadministered intermittently over a period of months. For example, thecompositions of the invention may be administered weekly for threeconsecutive weeks biannually (i.e., repeat the weekly dosing scheduleevery six months), or they may be administered once a month for a periodof two, three, four, five, six, seven, eight or more months. It will beappreciated that such administration regimens may be continued forextended periods (e.g., on the order of years) to maintain beneficialtherapeutic effects provided by initial treatments. In yet otherembodiments, such maintenance therapy may be effected following an acutedosing regimen designed to reduce the immediate symptoms of thedegenerative joint condition, disease or disorder, such asosteoarthritis. In most embodiments, however, the compositions of theinvention are administered to the patient according to the methodsdescribed herein at least until the symptoms of the joint disorder ordisease, such as OA, are alleviated or reduced. More commonly, thecompositions of the invention and methods of the invention are used fora period of time after the symptoms are reduced to a tolerable level orcompletely eliminated so as to result in an improvement in thephysiological structure of the joint by reducing or eliminating theunderlying physiological causes of the joint disease or disorder.

The amount of the compositions of the invention administered each timethroughout the treatment period can be the same; alternatively, theamount administered each time during the treatment period can vary(e.g., the amount administered at a given time can be more or less thanthe amount administered previously). For example, doses given duringmaintenance therapy may be lower than those administered during theacute phase of treatment. Appropriate dosing schedules depending on thespecific circumstances will be apparent to persons of ordinary skill inthe art.

It will be readily apparent to one of ordinary skill in the relevantarts that other suitable modifications and adaptations to the methodsand applications described herein are obvious and may be made withoutdeparting from the scope of the invention or any embodiment thereof.Having now described the present invention in detail, the same will bemore clearly understood by reference to the following examples, whichare included herewith for purposes of illustration only and are notintended to be limiting of the invention.

EXAMPLES Example 1 Effects of Intraarticular Administration of Anti-OAFormulation on Patient WOMAC and Lequesne Indices

In the present experiments, 18 white patients, mean age of 57.8 yearsand diagnoses of gonartrosis grade I to V according to the Kellgren andLawrence criteria were included in a clinical trial. The patientsreceived intra-articular injection of 10 mL of a solution of sodiumbicarbonate and calcium gluconate every month for up to 6 months. At theend of the treatment an intra-articular injection of 10 mL of a 1.77g/mol (hyperosmolar) solution of sodium chloride was administered. Theclinical efficacy measure of primary interest was the pain subscale fromthe Western Ontario University (WOMAC) and Lequesne indexes. At the6-months follow-up evaluations of the developed formula injected to theknees exhibited a greater symptoms improvement in 90% of the totalincluded patients (Table 1).

TABLE 1 Changes from baseline in Womac and Lequesne Indices of patientsinjected with the developed formula. Total patients Grade I Grade II-IIIGrade III-IV Grade V N 18 2 6 4 6 LEQUESNE INDEX Baseline score 19.72 ±8.97  7.00 ± 0.00 20.00 ± 11.71 19.00 ± 1.83  24.17 ± 6.74  Final score2.44 ± 4.45 0.00 ± 0.00 1.00 ± 1.26 3.50 ± 7.00 4.00 ± 5.25 Change−17.28 ± 8.27    −7.00 ± 0.00   −19.00 ± 10.90   −15.50 ± 5.80    −20.17± 5.91    Sig p < 0.001 p < 0.001 p < 0.010 p = 0.108 p < 0.010 WOMACINDEX Baseline score 16.94 ± 10.73 1.40 ± 1.98 20.51 ± 9.87  13.93 ±12.72 20.57 ± 7.83  Final score 0.52 ± 1.28 0.00 ± 0.00 0.62 ± 1.51 0.43± 0.85 0.67 ± 1.63 Change −16.42 ± 10.01   −1.40 ± 1.98   −19.89 ±8.68    −13.50 ± 11.89   −19.90 ± 7.30    Sig p < 0.001 p < 0.001 p <0.010 p < 0.050 p < 0.001

Example 2 Evaluation of the Comparative Efficacy of Kondrium™ andMethylprednisolone in the Treatment of Osteoarthritis of the Knee

Kondrium™ is the name of an exemplary pharmaceutical compositiondisclosed herein and in U.S. Patent Appl. No. 60/953,724 entitled“Composition and method for the treatment and prevention ofOsteoarthritis”. This composition activates the buffer capacity ofproteins that forms the cartilage which promotes the organification ofionized calcium, and also allows the linkage between chondrals and boneproteins. This study was designed to evaluate and compare the efficacyof Kondrium™ and methylprednisolone as active control in the treatmentof osteoarthritis (OA) of knee. Methylprednisolone was chosen forcomparison because at present it is the only drug medically accepted fortreatment of osteoarthritis.

Methods Study Design

This was a 16-week, randomized, double-blind, active-controlled,parallel-group study. The study received Ethics Committee approval, wasperformed in accordance with the ICH Harmonized Guidelines for Goodclinical Practice (GPC) and the Declaration of Helsinki. All patientsprovided written, informed consent before the start of the study.

Patients, investigator staff, persons performing the assessment, anddata analysts remained blinded to the identity of the treatment from thetime of randomization until data base lock. Treatments were allidentical in packaging, labeling, schedule of administration andappearance.

Patients

117 patients with OA of the knee (according to the American College of

Rheumatology criteria) were included in the study. Patients wereenrolled by public advertising and were studied at the San Jose Hospitalin Queretaro, México. Entry criteria included: willingness toparticipate in the study, male and female patients aged at least 40years of age with symptomatic evidence of OA in the knee for at least 1year, radiographic evidence of Kellgren and Lawrence grade II to IV OAof the knee, and no intra-articular injection of corticosteroids withinthe last 3 months. Patients were excluded if they had: any history ofadverse reaction to the study drugs, current pregnancy status,uncontrolled hypertension, active infection, undergonesurgery/arthroscopy within three months, diagnosis of radiographic OA ofKellgren and Lawrence grade I.

Sample size was calculated based on the assumption of a) a minimumclinically significant change in the global score of Lequesne and WOMACscales equal to 3.1 between the treatments and the control groups, b) apopulation standard deviation of the difference between Kondrium™ andmethylprednisolone equal to 5.0% of the maximum pain score, c) atwo-sided alpha level of 0.05, d) a beta level of 0.2 (80% power) d) anda drop-out rate of 20% . With these figures, 114 subjects were necessaryaccording with the study design.

Concomitant treatment with analgesic (other than rescue medication) andsystemic corticosteroids was not allowed during the study. Patients werepermitted to use rescue medication (acetaminophen 3 g/day, paracetamol)during the study, although the use of rescue medication was prohibitedbefore the baseline clinic visit.

Study Procedure

Participants were assessed in-person during 6 visits conducted atmonthly intervals. After giving written informed consent (visit #1),patients were screened and selected according to the predeterminedcriteria. Visit # 2 was the baseline assessment. During this visitselected patients were assigned a unique patient identification numberand randomized to receive 1 intra-articular monthly injection (10 mL) ofKondrium™, Kondrium™-F or methylprednisolone (80 mg) 1 month apartduring the next 3 months (visits 3, 4 and 5). Visit #3, #4 and #5 servedas a midpoint assessment and visit #6 was the final assessmentcorresponding to the end of the intervention period of the study.Kondrium™ is an aqueous formulation that contains 6.75% (w/v) sodiumbicarbonate and 0.75% (w/v) calcium gluconate. Kondrium™-F is an aqueousformulation that contains 6.75% (w/v) sodium bicarbonate and 1.5% (w/v)calcium gluconate.

Compliance with treatment was assessed by counting the number of unusedvials and the number of times injection treatment was received.

Efficacy Assessments

The study's primary objective was to demonstrate the superiority ofKondrium™ and Kondrium™-F compared with methylprednisolone in thetreatment of patients suffering OA in the knee. The primary efficacyvariable was the change from the baseline to final assessment in theWestern Ontario and McMastern University OA index (WOMAC subscale scorefor pain), and Lequesne's functional index.

Safety and Tolerability Assessment

Subjects were informed of all possible side effects, benefits andpotential risks of the study during the first visit. Adverse reactionswere monitored with health diaries, nursing assessment and clinicalinterviews in-person at visits #2, 3, 4, 5 and 6. Subjects were alsoasked to record any adverse symptoms and inform the correspondentphysician immediately. All the adverse effects reported by the patientor discovered by the investigator during the study period were recordedand evaluated in terms of seriousness, severity and potentialrelationship to study medication. Safety assessment consisted of routinelaboratory tests (haematology, biochemistry and urinalysis), measurementof vital signs and electrocardiogram recordings, which were completed atscreening/baseline and at study end.

Statistical Analysis

Data analysis was performed using SPSS for Windows version 10.0.Baseline demographic variables and compliance were analyzed by means ofthe χ² test. A univariate analysis of variance (ANOVA) was used todetermine whether the three treatment groups differed in mean values ofchange from a baseline in WOMAC and Lequesne's functional index.Treatment effect is shown as the main effect controlled by the baselinevalues. Pairwise comparisons between treatments were done with the LSDtest. All statistical tests were performed at the 0.05 level ofsignificance.

Results

A total of 161 patients were initially screened for the study betweenDecember 2007 and February 2008. Forty-four did not meet the inclusioncriteria and were excluded from the study. The remaining 117 subjectswere randomly assigned to treatment with one of the three studymedications (FIG. 1), and all of them received the allocatedintervention. Twelve patients (10.2%) withdrew the study, 4 from theKondrium™ group (3 due to personal reasons and 1 for unsatisfactorytherapeutic effect), 4 from Kondrium™-F group (3 due to personal reasonand 1 for unsatisfactory therapeutic effect) and 4 from themethylprednisolone group (3 for personal reasons and one forunsatisfactory therapeutic effect).

The baseline demographic characteristics of the 117 patients enrolled inthe study did not differ between groups, thus were not considered tohave influenced the outcome of the study (Table 2). The majority of thepatients were female (80.2%), mean age was 54.7±9.06 years and meandisease duration was about 7 years. A high proportion of subjects inthis study were obese, as indicated by an average body mass indexgreater than 30. Radiographic analysis showed no significant differenceamong treatment groups in the distribution of severity of joint-spacenarrowing and marginal osteophyte formation within each kneecompartment. In the majority of the patients (80%), pain intensity inthe target knee was from moderate to severe. At the end of the study,patients in all three groups showed an improvement in score for thethree summary measurements of pain, stiffness and physical functioning,and for the overall WOMAC and Lequesne score with respect to thebaseline (Tables 3,4). The improvement in WOMAC total score was greatestand significantly different in both the Kondrium™ and Kondrium™-F groupswith respect to methylprednisolone group. The mean change in WOMAC totalscore was −11.28, −10.40 and −7.34 for the groups receiving Kondrium™,Kondrium™-F and methylprednisolone respectively. No differences wereobserved between Kondrium™ and Kondrium™-F groups (Table 3; FIG. 2). Themean changes in the Lequesne's functional index also differedsignificantly between the Kondrium™ and Kondrium™-F groups and themethylprednisolone group. The mean change in the Lequesne's functionalindex was −9.33 for the group receiving Kondrium™, −8.46 for Kondrium™-Fand −5.2 for the group receiving methylprednisolone (Table 4; FIG. 3).

The percentage of patients who experienced adverse events during thisstudy did not differ among the three groups, whereas gonalgia was themost common adverse event reported in three groups. However, gonalgiadisappeared within 1-5 days.

This study was intended to evaluate the efficacy and safety of the useof intraarticular injections of Kondrium™ for the treatment ofosteoarthritis of the knee. We have shown that four months of treatmentwith Kondrium™ or Kondrium™-F is significantly more effective thanmethylprednisolone with respect to changes in WOMAC total score andLequesne's functional index. This superiority of Kondrium™ andKondrium™-F indicates the genuine efficacy of these exemplarycompositions of the present invention, which were more effective thanmethylprednisolone in this study.

This study also demonstrated that Kondrium™ and Kondrium™-F treatmentwas safe and free from serious adverse effect. The positive effect andthe absence of serious adverse events of the sodium bicarbonate/calciumgluconate administration make this procedure an attractive alternativetreatment for patients with oateoarthritis of the knee.

TABLE 2 Baseline demographic characteristics of patients withosteoarthritis of the knee, by study group Patient group Kondrium ™Kondrium ™-F Methylprednisolone n = 34 n = 36 n = 35 Female (%) 91.779.5 69.4 Male (%)  8.3 20.5 30.6 Age, mean (SD), yr 55.49 (9.76) 54.46(8.83) 54.47 (8.81) BMI, mean (SD), 31.06 (4.92) 31.63 (4.77) 30.46(4.86) Kg/m² BMI > 30 (%) 47.2 64.1 50  

TABLE 3 WOMAC subscale measures after 4 months of treatment. *Indicatesignificantly different with respect to methylprednisolone group (p <0.05, LSD test). Patient group Kondrium ™ Kondrium ™-FMethylprednisolone n = 34 n = 36 n = 35 Pain Baseline, mean (95% CI)6.15 (5.30 to 7.0) 6.08 (5.25 to 6.91) 4.72 (3.52 to 6.92) Final, mean(95% CI) 2.00 (1.39 to 2.61) 2.20 (1.32 to 3.08) 2.57 (1.70 to 3.44)Change, mean (95% CI) −3.82 (−4.61 to −3.03) −3.59 (−4.33 to −2.86)−2.76 (−3.52 to −2.00) Stiffness Baseline, mean (95% CI) 5.97 (5.24 to6.69) 5.98 (5.15 to 6.82) 4.79 (3.94 to 5.64) Final, mean (95% CI) 2.11(1.51 to 2.72) 2.17 (1.46 to 2.89) 2.77 (1.84 to 3.70) Change, mean (95%CI −3.65 (−4.36 to −2.94)* −3.60 (−4.26 to −2.94)* −2.42 (−3.10 to−1.74) Physical functioning Baseline, mean (95% CI) 17.80 (15.89 to19.71) 17.85 (15.76 to 19.93) 14.47 (11.85 to 17.09) Final, mean (95%CI) 5.97 (4.23 to 7.72) 6.89 (4.62 to 9.15) 8.19 (5.48 to 10.91) Change,mean (95% CI) −11.28 (13.43 to −9.13)* −10.40 (12.40 to −8.39)* −7.34(−9.41 to −5.27) *Significantly different from Methylprednisolonecontrol group in a univariate analysis of variance controlled by thebaseline value and LSD test for pairwise comparisons

TABLE 4 Lequesne functional index subscales measures after 4 months oftreatment. *Indicate significantly different with respect to methylprednisolone group (p < 0.05, LSD test). Patient group Kondrium ™Kondrium ™-F Methylprednisolone n = 34 n = 36 n = 35 Pain Baseline, mean(95% CI) 5.58 (5.06 to 6.10) 5.40 (4.93 to 5.87) 4.34 (3.67 to 5.01)Final, mean (95% CI) 2.62 (2.04 to 3.19) 2.40 (1.68 to 3.12) 2.86 (2.08to 3.64) Change, mean (95% CI) −2.65 (−3.39 to −1.92) −2.80 (−3.48 to−2.13) −1.96 (−2.68 to −1.25) Maximum Walking Distance Baseline, mean(95% CI) 4.62 (3.74 to 5.50) 4.03 (3.38 to 4.68) 3.24 (2.42 to 4.06)Final, mean (95% CI) 1.73 (0.95 to 2.51) 2.07 (1.33 to 2.80) 2.90 (2.07to 3.72) Change, mean (95% CI −2.49 (−3.26 to −1.72)* −1.91 (−2.62 to−1.21)* −0.75 (−1.48 to −0.02) Normal activities Baseline, mean (95% CI)8.58 (7.16 to 10.00) 7.53 (6.70 to 8.36) 6.93 (5.85 to 8.01) Final, mean(95% CI) 4.08 (3.37 to 4.78) 3.90 (3.18 to 4.62) 4.62 (3.52 to 5.72)Change, mean (95% CI) −3.87 (−4.73 to −3.01) −3.71 (−4.50 to −2.92)−2.80 (−3.61 to −1.99) *Significantly different from Methylprednisolonecontrol group in a univariate analysis of variance controlled by thebaseline value and LSD test for pairwise comparisons

Having now fully described the present invention in some detail by wayof illustration and example for purposes of clarity of understanding, itwill be obvious to one of ordinary skill in the art that the same can beperformed by modifying or changing the invention within a wide andequivalent range of conditions, formulations and other parameterswithout affecting the scope of the invention or any specific embodimentthereof, and that such modifications or changes are intended to beencompassed within the scope of the appended claims.

All publications, patents and patent applications mentioned in thisspecification are indicative of the level of skill of those skilled inthe art to which this invention pertains, and are herein incorporated byreference to the same extent as if each individual publication, patentor patent application was specifically and individually indicated to beincorporated by reference.

1.-25. (canceled)
 26. A method of treating osteoarthritis in a subject,comprising administering by intraarticular injection to a subject inneed thereof a mixture of sodium bicarbonate and calcium gluconate in anamount effective to treat the symptoms or underlying physiologicalcauses of osteoarthritis.
 27. The method of claim 26, wherein saidsodium bicarbonate is present at a concentration of from about 0.1% toabout 99.9% (w/v), and wherein said calcium gluconate is present at aconcentration of from about 0.1% to about 99.9% (w/v).
 28. The method ofclaim 26, wherein said sodium bicarbonate is present at a concentrationof from about 5%-10% (w/v), and wherein said calcium gluconate ispresent at a concentration of from about 0.5%-5% (w/v).
 29. The methodof claim 26, wherein said sodium bicarbonate is present at aconcentration of from about 6%-8% (w/v).
 30. The method of claim 26,wherein said sodium bicarbonate is present at a concentration of fromabout 6%-7% (w/v).
 31. The method of claim 26, wherein said sodiumbicarbonate is present at a concentration of about 6.75% (w/v).
 32. Themethod of claim 26, wherein said calcium gluconate is present at aconcentration of from about 0.5%-2.5% (w/v).
 33. The method of claim 26,wherein said calcium gluconate is present at a concentration of fromabout 0.75%-2% (w/v).
 34. The method of claim 26, wherein said calciumgluconate is present at a concentration of about 0.75% (w/v) or about1.5% (w/v).
 35. The method of claim 26, wherein said sodium bicarbonateis present at a concentration of about 6.75% (w/v) and wherein saidcalcium gluconate is present at a concentration of about 0.75% (w/v) orabout 1.5% (w/v).
 36. The method of claim 26, wherein said compositionis an aqueous solution.
 37. (canceled)
 38. The method of claim 26,wherein said composition further comprises one or more additionalcomponents selected from the group consisting of at least one NSAID, atleast one NsIDI, at least one COX-1 inhibitor, at least one COX-2inhibitor, at least one corticosterioid, at least one glycosaminoglycan,at least one proteoglycan, at least one hyaluronic acid, and synovialfluid.
 39. The method of claim 38, wherein said at least one NSAID isselected from the group consisting of diclofenac, aceclofenac,ketorolac, ibuprofen, flurbiprofen, ketoprofen, and naproxen, andpharmaceutically acceptable derivatives, salts or esters thereof. 40.The method of claim 38, wherein said at least one NsIDI is selected fromthe group consisting of a calcineurin inhibitor, rapamycin (sirolimus),fujimycin (tacrolimus) and everolimus.
 41. The method of claim 38,wherein said at least one COX-1 inhibitor is selected from the groupconsisting of aspirin, ibuprofen and naproxen.
 42. The method of claim38, wherein said at least one COX-2 inhibitor is selected from the groupconsisting of celecoxib, rofecoxib, valdecoxib, lumiracoxib, meloxicam,tramadol, lumiracoxib, etoricoxib and nimesulide.
 43. The method ofclaim 38, wherein said at least one corticosteroid is selected from thegroup consisting of betamethasone, budesonide, cortisone, dexamethasone,hydrocortisone, methylprednisolone, prednisolone, prednisone andtriamcinolone.
 44. The method of claim 38, wherein said at least oneglycosaminoglycan is glucosamine or glucosamine sulfate.
 45. The methodof claim 38, wherein said at least one proteoglycan is heparan sulfateproteoglycan or chondroitin sulfate proteoglycan. 46.-50. (canceled) 51.The method of claim 26, wherein said subject is a human.
 52. The methodof claim 26, further comprising administration to said subject of ahyperosmolar solution of sodium chloride.
 53. The method of claim 52,wherein the concentration of sodium chloride in said hyperosmolarsolution is about 1.77 g/mol.
 54. The method of claim 26, wherein saidsodium bicarbonate is present at a concentration of from about 2.5%-25%(w/v), and wherein said calcium gluconate is present at a concentrationof from about 0.5%-5% (w/v).
 55. The method of claim 26, wherein saidsodium bicarbonate is present at a concentration of about 6.75% (w/v),and wherein said calcium gluconate is present at a concentration ofabout 1.5% (w/v).
 56. The method of claim 26, wherein said sodiumbicarbonate is present at a concentration of about 6.75% (w/v), andwherein said calcium gluconate is present at a concentration of about0.75(w/v).%
 57. A method of treating osteoarthritis in a subject,comprising administering by intraarticular injection to a subject inneed thereof a mixture consistently essentially of about 6.75% (w/v)sodium bicarbonate and about 1.5% (w/v) calcium gluconate to treat thesymptoms or underlying physiological causes of osteoarthritis.
 58. Amethod of treating osteoarthritis in a subject, comprising administeringby intraarticular injection to a subject in need thereof a mixtureconsistently essentially of about 6.75% (w/v) sodium bicarbonate andabout 0.75% (w/v) calcium gluconate to treat the symptoms or underlyingphysiological causes of osteoarthritis.